Planning & Development
1400 North Boulevard Tampa, FL 33607
(813) 274-3100
CHANGE OF PRIVATE PROVIDER
REV 01/21/20
NOTICE TO BUILDING OFFICAL
CHANGE OF PRIVATE PROVIDER FIRM AND/OR SERVICES
Changes to the originally approved Private Provider Firm or services shall be noticed to the Building Official
within one business day after any change. Note that the new Private Provider firm and its DAR’s must be duly
registered with the City of Tampa in order for the change to be authorized.
City of Tampa Permit No.:____________________________________________________________________
Project Address:_________________________________________________ Project Folio No.: ___________
Fee Owner Name (Printed): __________________________________________________________________
CHANGE REQUESTED (check all that apply)
Change of Private Provider Firm to Alternate Private Provider Firm Change of Services
Change from Private Provider Firm to City of Tampa
EXISTING PRIVATE PROVIDER FIRM / QUALIFIER
Name of Firm:_____________________________________________________________________________
Qualifier: ___ License No.:______________________________
Business Address:___________________________________________________________________________
Office Phone: Fax:_____________________________________
NEW PRIVATE PROVIDER FIRM / QUALIFIER No Change
Name of Firm:______________________________________________________________________________
Qualifier: ___ License No.:_______________________________
Business Address:____________________________________________________________________________
Office Phone: Fax:________________________________
Planning & Development
1400 North Boulevard Tampa, FL 33607
(813) 274-3100
CHANGE OF PRIVATE PROVIDER
REV 01/21/20
CHANGE OF SERVICES
Original Services provided: (select all that apply):
Plan Review Only Inspections Only Plan Review and Inspections
New Services to be provided: (select all that apply):
No Change Plan Review Only Inspections Only Plan Review and Inspections
I, ____________________________________, the fee owner of the property referenced above, hereby affirm
that I request the change of Private Provider and/or services as indicated above effective on
___________________________________ ____________.
_________________________________________ ________________________________________
Printed or Typed Name of Fee Owner of Property Signature of Fee Owner of Property
NOTARY
STATE OF FLORIDA
COUNTY OF
SWORN TO (OR AFFIRMED) AND SUBSCRIBED before me this day of __________,
20 , by (name of person making statement).
Signature of Notary Public State of Florida
(NOTARY SEAL)
Printed or Typed Name of Notary Public
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